Scales in Parkinsons disease

Introduction The UPDRS (Unified Parkinsons disease rating score), Hoehn & Yahr and Schwab & England scales are the scales in common practice for Parkinsons disease. Their utility is that they objectively rate an individual patients disability at a particular moment in time. Each scale score is a reflection of disease burden on the individual patient and is useful in describing disease progression and treatment response with time. The UPDRS is scored from a total of 195 points; higher scores reflect worsening disability.

Modified Hoehn and Yahr staging

Stage Stage Stage Stage Stage Stage Stage Stage 0 1 1.5 2 2.5 3 4 5 No signs of disease Unilateral disease Unilateral plus axial involvement Bilateral disease, without impairment of balance Mild bilateral disease, with recovery on pull test Mild to moderate bilateral disease; some postural instability; physically independent Severe disability; still able to walk or stand unassisted Wheelchair bound or bedridden unless aided

Schwab & England Activities of Daily Living scale

100% 90% Completely independent. Able to do all chores w/o slowness, difficulty, or impairment. Essentially normal. Unaware of any difficulty. Completely independent. Able to do all chores with some degree of slowness, difficulty and impairment. May take twice as long. Beginning to be aware of difficulty. Completely independent in most chores. Takes twice as long. Conscious of difficulty and slowing. Not completely independent. More difficulty with some chores. X 3-4 as long in some. May spend a large part of the day with chores. Some dependency. Can do most chores, but exceedingly slowly and with much effort. Errors, some impossible. More dependent. Help with 1/2 of chores. Difficulty with everything. Very dependant. Can assist with all chores but few alone. With effort, now and then does a few chores alone or begins alone. Much help needed. Nothing alone. Can do some slight help with some chores. Severe invalid. Totally dependant, helpless. Complete invalid. Vegetative functions such as swallowing, bladder and bowel function are not functioning. Bedridden.

80% 70% 60% 50% 40% 30% 20% 10% 0%

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Unified Parkinsons disease Rating Scale (UPDRS)

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Mentation, Behaviour & Mood

Intellectual impairment 0 = none 1 = mild, consistent forgetfulness 2 = moderate, difficulty with complex problems 3 = severe, disorientation for time & place 4 = severe, help with personal care. Cannot be left alone Thought disorder 0 = none 1 = vivid dreaming 2 = benign" hallucination with insight retained 3 = hallucination or delusions without insight 4 = persistent hallucination, delusions, or florid psychosis Depression 0 = not present 1 = periods of sadness or guilt > normal, never sustained for days/weeks 2 = sustained depression for >1 week 3 = vegetative symptoms (insomnia, anorexia, weight loss) 4 = vegetative symptoms and suicidal thoughts Motivation/Initiative 0 = normal 1 = less assertive than usual, more passive 2 = loss of initiative/disinterest in elective activities 3 = loss of initiative/disinterest in routine activities 4 = withdrawn, complete loss of motivation

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Dressing 0 = Normal 1 = Somewhat slow, but no help needed 2 = Occasional assistance with buttons, arms in sleeves 3 = Considerable help, can do some things alone 4 = Helpless Hygiene 0 = Normal 1 = Somewhat slow, no help needed 2 = Help to shower/bathe 3 = Assistance for washing hair, brushing teeth & hair 4 =Foley catheter or pads Turning in bed & adjusting bed clothes 0 = Normal 1 = Somewhat slow & clumsy, no help needed 2 = Turns alone or adjusts sheets, but with difficulty 3 = Can initiate, but not turn or adjust sheets alone 4 = Helpless Falling 0 = None 1 = Rare falling 2 = Occasionally falls, < 1 per day 3 = Falls on average once per day 4 = Falls > once per day Freezing when walking 0 = None 1 = Rare freezing; may have start-hesitation 2 = Occasional freezing when walking 3 = Frequent freezing. Occasional falls resulting 4 = Frequent falls from freezing Walking 0 = Normal 1 = Mild difficulty. May not swing arm or may drag leg 2 = Moderate difficulty, but requires no assistance 3 = Severe disturbance, requires assistance 4 = Cannot walk, even with assistance Tremor (Symptomatic complaint in any body part) 0 = Absent 1 = Slight & infrequently present 2 = Moderate; bothersome to patient 3 = Severe; interferes with many activities 4 = Marked; interferes with most activities Sensory complaints relating to parkinsonism 0 = None 1 = Occasional numbness, tingling or aching 2 = Frequent numbness, tingling or aching 3 = Frequent painful sensations 4 = Excruciating pain

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II
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Activities of Daily Living

Speech 0 = Normal 1 = Mildly affected 2 = Moderately affected. Sometimes asked to repeat statements 3 = Severely affected. Frequently asked to repeat statements 4 = Unintelligible most of the time Salivation 0 = Normal 1 = Slight saliva excess. Some night-time drooling 2 = Moderately excessive saliva; minimal drooling 3 = Marked excess saliva with some drooling 4 = Marked drooling, requires constant tissue/handkerchief Swallowing 0 = Normal 1 = Rare choking 2 = Occasional choking 3 = Requires soft food 4 =Requires nasogastric tube or gastrostomy feeding Handwriting 0 = Normal 1 = Slightly slow or small 2 = Moderately slow/small; all words are legible 3 = Severely affected; not all words are legible 4 = The majority of words are not legible Cutting food and handling utensils 0 = Normal 1 = Somewhat slow and clumsy, but no help needed 2 = Can cut most foods slowly; some help needed 3 = Food must be cut by someone, but can still feed slowly 4 = Needs to be fed

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III
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Motor examination
Speech 0 = Normal 1 = Slight loss of expression, diction or volume 2 = Monotone, slurred but understandable 3 = Marked impairment, difficult to understand 4 = Unintelligible Facial expression 0 = Normal 1 = Minimal hypomimia, could be poker face 2 = Definite diminution of expression 3 = Moderate hypomimia; lips parted some of the time 4 = Masked or fixed facies; lips parted inch or more

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Tremor at rest - Right upper limb 0 = Absent 1 = Slight, infrequently present 2 = Mild amplitude & persistent or moderate & intermittent 3 = Moderate amplitude, present most of the time 4 = Marked amplitude, present most of the time Tremor at rest - Left upper limb 0 = Absent 1 = Slight, infrequently present 2 = Mild amplitude & persistent or moderate & intermittent 3 = Moderate amplitude, present most of the time 4 = Marked amplitude, present most of the time Tremor at rest - Right lower limb 0 = Absent 1 = Slight, infrequently present 2 = Mild amplitude & persistent or moderate & intermittent 3 = Moderate amplitude, present most of the time 4 = Marked amplitude, present most of the time Tremor at rest Left lower limb 0 = Absent 1 = Slight, infrequently present 2 = Mild amplitude & persistent or moderate & intermittent 3 = Moderate amplitude, present most of the time 4 = Marked amplitude, present most of the time Action or posture tremor of hands Right hand 0 = Absent 1 = Slight, present with action 2 = Moderate in amplitude, present with action 3 = Moderate in amplitude, with posture holding & action 4 = Marked in amplitude; interferes with feeding Action or posture tremor of hands Left hand 0 = Absent 1 = Slight, present with action 2 = Moderate in amplitude, present with action 3 = Moderate in amplitude, with posture holding & action 4 = Marked in amplitude; interferes with feeding Rigidity (judged on passive movement of major joints with patient relaxed in the sitting position) 23

Rigidity right lower limb 0 = Absent 1 = Slight, detectable only with mirror movements 2 = Mild to moderate 3 = Marked, but full range of movement easily achieved 4 = Severe, range of movement achieved with difficulty Rigidity left lower limb 0 = Absent 1 = Slight, detectable only with mirror movements 2 = Mild to moderate 3 = Marked, but full range of movement easily achieved 4 = Severe, range of movement achieved with difficulty Finger taps (patient taps thumb with index finger in rapid succession with widest amplitude possible) Finger taps - Right hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task Finger taps - Left hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task 24 Hand movements (Patient opens & closes hands in rapid succession with widest amplitude possible) Hand movements Right hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task Hand movements Left hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task 25 Rapidly alternating hand movements (pronationsupination movements with as large an amplitude as possible) Rapidly alternating hand movements Right hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task Rapidly alternating hand movements Left hand 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task

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Rigidity - neck 0 = Absent 1 = Slight, detectable only with mirror movements 2 = Mild to moderate 3 = Marked, but full range of movement easily achieved 4 = Severe, range of movement achieved with difficulty Rigidity Right upper limb 0 = Absent 1 = Slight, detectable only with mirror movements 2 = Mild to moderate 3 = Marked, but full range of movement easily achieved 4 = Severe, range of movement achieved with difficulty Rigidity left upper limb 0 = Absent 1 = Slight, detectable only with mirror movements 2 = Mild to moderate 3 = Marked, but full range of movement easily achieved 4 = Severe, range of movement achieved with difficulty

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Leg agility (rapid heel tapping. Amplitude 3 inches) Leg agility Right heel 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task Leg agility Left heel 0 = Normal 1 = Mild slowing and/or reduction in amplitude 2 = Definite & early fatiguing; occasional arrests 3 = Frequent hesitation in initiation or arrests in movement 4 = Can barely perform the task Arising from a chair (patients arms across chest) 0 = Normal 1 = Slow; or may need more than 1 attempt 2 = Pushes self up from arms of seat 3 = May fall back or try more than once to get up 4 =Unable to arise without help Posture 0 = Normal erect 1 = Slightly stooped; could be normal for older person 2 = Moderately stooped; can be slightly leaning to 1 side 3 = Severely stooped with kyphosis; can be moderately leaning to one side 4 = Marked flexion with extreme abnormality of posture Gait 0 = Normal 1 = Walks slowly, short steps but no festination 2 = Walks with difficulty but without assistance; festination, short steps or propulsion 3 = Severely disturbed gait; requires assistance 4 =Cannot walk even with assistance Postural stability (pull test, may have practice runs) 0 = Normal 1 = Retropulsion, but recovers unaided 2 = Absence of posture response, would fall if not caught 3 = Very unstable, spontaneous loss of balance 4 = Unable to stand without assistance Body bradykinesia & hypokinesia (slowness, hesitancy, decreased arm swing, small amplitude & poverty of movement) 0 = None 1 = Minimal slowness, deliberate character, possibly reduced amplitude 2 = Mild slowness, poverty or small amplitude of movement 3 = Moderate slowness, poverty or small amplitude of movement 4 = Marked slowness, poverty or small amplitude of movement

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Complications of therapy (in the past week) DYSKINESIAS

Duration: What proportions of the waking day are dyskinesias present? 0 = None 1 = 1 25% of the day 2 = 26 50% of the day 3 = 51 75% of the day 4 =76 100% of the day Disability: How disabling are the dyskinesias? 0 = Not disabling 1 = Mildly disabling 2 = Moderately disabling 3 = Severely disabling 4 =Completely disabled Painful dyskinesias: How painful are the dyskinesias? 0 = None 1 = Slight 2 = Moderate 3 = Severe 4 =Marked Presence of early morning dystonias 0 = No 1 = Yes

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CLINICAL FLUCTUATIONS

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Are any off periods predictable as to timing after medication dosing? 0 = No 1 = Yes Are any off periods unpredictable as to timing after medication dosing? 0 = No 1 = Yes Do any of the off periods come on suddenly (seconds)? 0 = No 1 = Yes What percentage of the waking day is the patient off on average? 0 = None 1 = 1 25% of the day 2 = 26 50% of the day 3 = 51 75% of the day 4 =76 100% of the day

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C
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OTHER COMPLICATIONS
Does the patient have anorexia nauseas or vomiting? 0 = No 1 = Yes Does the patient have any sleep disturbance? 0 = No 1 = Yes Does the patient have symptomatic orthostasis? 0 = No 1 = Yes

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